Showing papers in "BMC Family Practice in 2013"

Frailty prevalence and slow walking speed in persons age 65 and older: implications for primary care

Abstract: Background: Frailty in the elderly increases their vulnerability and leads to a greater risk of adverse events. According to various studies, the prevalence of the frailty syndrome in persons age 65 and over ranges between 3% and 37%, depending on age and sex. Walking speed in itself is considered a simple indicator of health status and of survival in older persons. Detecting frailty in primary care consultations can help improve care of the elderly, and walking speed may be an indicator that could facilitate the early diagnosis of frailty in primary care. The objective of this work was to estimate frailty-syndrome prevalence and walking speed in an urban population aged 65 years and over, and to analyze the relationship between the two indicators from the perspective of early diagnosis of frailty in the primary care setting. Methods: Population cohort of persons age 65 and over from two urban neighborhoods in northern Madrid (Spain). Cross-sectional analysis. Bivariate and multivariate analysis with binary logistic regression to study the variables associated with frailty. Different cut-off points between 0.4 and 1.4 m/s were used to study walking speed in this population. The relationship between frailty and walking speed was analyzed using likelihood ratios. Results: The study sample comprised 1,327 individuals age 65 and older with mean age 75.41 ± 7.41 years; 53.4% were women. Estimated frailty in the study population was 10.5% [95% CI: 8.9-12.3]. Frailty increased with age (OR = 1.14; 95% CI: 1.10-1.19) and was associated with poor self-rated health (OR = 2.52; 95% CI: 1.43-4.44), number of drugs prescribed (OR = 1.17; 95% CI: 1.08-1.26) and disability (OR = 6.58; 95% CI: 3.92-11.05). Walking speed less than 0.8 m/s was found in 42.6% of cases and in 56.4% of persons age 75 and over. Walking speed greater than 0.9 m/s ruled out frailty in the study sample. Persons age 75 and older with walking speed <0.8 m/s are at particularly high risk of frailty (32.1%). Conclusions: Frailty-syndrome prevalence is high in persons aged 75 and over. Detection of walking speed <0.8 m/s is a simple approach to the diagnosis of frailty in the primary care setting.

Effects of self-care, self-efficacy, social support on glycemic control in adults with type 2 diabetes

Abstract: A number of studies have examined the influence of self-efficacy, social support and patient-provider communication (PPC) on self-care and glycemic control. Relatively few studies have tested the pathways through which these constructs operate to improve glycemic control, however. We used structural equation modeling to examine a conceptual model that hypothesizes how self-efficacy, social support and patient-provider communication influence glycemic control through self-care behaviors in Chinese adults with type 2 diabetes. We conducted a cross-sectional study of 222 Chinese adults with type 2 diabetes in one primary care center. We collected information on demographics, self-efficacy, social support, patient-provider communication (PPC) and diabetes self-care. Hemoglobin A1c (HbA1c) values were also obtained. Measured variable path analyses were used to determine the predicted pathways linking self-efficacy, social support and PPC to diabetes self-care and glycemic control. Diabetes self-care had a direct effect on glycemic control (β = −0.21, p = .007), No direct effect was observed for self-efficacy, social support or PPC on glycemic control. There were significant positive direct paths from self-efficacy (β = 0.32, p < .001), social support (β = 0.17, p = .009) and PPC (β = 0.14, p = .029) to diabetes self-care. All of them had an indirect effect on HbA1c (β =–0.06, β =–0.04, β =–0.03 respectively). Additionally, PPC was positively associated with social support (γ = 0.32, p < .001). Having better provider-patient communication, having social support, and having higher self-efficacy was associated with performing diabetes self-care behaviors; and these behaviors were directly linked to glycemic control. So longitudinal studies are needed to explore the effect of self-efficacy, social support and PPC on changes in diabetes self-care behaviors and glycemic control.

Family physicians’ diagnostic gut feelings are measurable: construct validation of a questionnaire

Abstract: Family physicians perceive that gut feelings, i.e. a ‘sense of reassurance’ or a ‘sense of alarm’, play a substantial role in diagnostic reasoning. A measuring instrument is desirable for further research. Our objective is to validate a questionnaire measuring the presence of gut feelings in diagnostic reasoning. We constructed 16 case vignettes from real practice situations and used the accompanying ‘sense of reassurance’ or the ‘sense of alarm’ as reference labels. Based on the results of an initial study (26 family physicians), we divided the case vignettes into a group involving a clear role for the sense of reassurance or the sense of alarm and a group involving an ambiguous role. 49 experienced family physicians evaluated each 10 vignettes using the questionnaire. Construct validity was assessed by testing hypotheses and an internal consistency procedure was performed. As hypothesized we found that the correlations between the reference labels and corresponding items were high for the clear-case vignettes (0.59 – 0.72) and low for the ambiguous-case vignettes (0.08 – 0.23). The agreement between the classification in clear sense of reassurance, clear sense of alarm and ambiguous case vignettes as derived from the initial study and the study population’s judgments was substantial (Kappa = 0.62). Factor analysis showed one factor with opposites for sense of reassurance and sense of alarm items. The questionnaire’s internal consistency was high (0.91). We provided a linguistic validated English-language text of the questionnaire. The questionnaire appears to be valid. It enables quantitative research into the role of gut feelings and their diagnostic value in family physicians’ diagnostic reasoning.

Depression, anxiety and stress symptoms among diabetics in Malaysia: a cross sectional study in an urban primary care setting

Abstract: Diabetes mellitus is a highly prevalent condition in Malaysia, increasing from 11.6% in 2006 to 15.2% in 2011 among individuals 18 years and above. Co-morbid depression in diabetics is associated with hyperglycemia, diabetic complications and increased health care costs. The aims of this study are to determine the prevalence and predictors of depression, anxiety and stress symptoms in Type II diabetics attending government primary care facilities in the urban area of Klang Valley, Malaysia. The study was cross sectional in design and carried out in 12 randomly selected primary care government clinics in the Klang Valley, Malaysia. A total of 2508 eligible consenting respondents participated in the study. The Depression, Anxiety and Stress Scale (DASS) 21 questionnaire was used to measure depression, anxiety and stress symptoms. Data was analyzed using the SPSS version 16 software using both descriptive and inferential statistics. The prevalence of depression, anxiety and stress symptoms among Type II diabetics were 11.5%, 30.5% and 12.5% respectively. Using multiple logistic regression, females, Asian Indians, marital status (never married, divorced/widowed/separated), a family history of psychiatric illness, less than 2 years duration of diabetes and current alcohol consumption were found to be significant predictors of depression. For anxiety, unemployment, housewives, HbA1c level of more than 8.5%, a family history of psychiatric illness, life events and lack of physical activity were independent risk factors. Stress was significantly associated with females, HbA1c level of more than 8.5%, presence of co-morbidity, a family history of psychiatric illness, life events and current alcohol consumption. For depression (adjusted OR 2.8, 95% CI 1.1; 7.0), anxiety (adjusted OR 2.4, 95% CI 1.1;5.5) and stress (adjusted OR 4.2, 95% CI 1.8; 9.8), a family history of psychiatric illness was the strongest predictor. We found the prevalence of depression, anxiety and stress symptoms to be high among Type II diabetics, with almost a third being classified as anxious. Screening of high risk Type II diabetics for depression, anxiety and stress symptoms in the primary care setting is recommended at regular intervals.

Effect of facemasks on empathy and relational continuity: a randomised controlled trial in primary care

Abstract: Background: There is limited evidence to support the use of facemasks in preventing infection for primary care professionals. Negative effects on communication has been suggested when the physician wears a facemask. As communication skills and doctor patient relationship are essential to primary care consultations, the effects of doctor’s facemask wearing were explored. Method: A randomised controlled study was conducted in primary care to explore the effects of doctors wearing facemasks on patients’ perception of doctors’ empathy, patient enablement and patient satisfaction. Primary care doctors were randomized to mask wearing and non mask wearing clinical consultations in public primary care clinics in Hong Kong. Patients’ views were gathered using the Consultation and Relational Empathy (CARE) Measure, Patient Enablement Instrument (PEI) and an overall satisfaction rating scale. The effects of face mask wearing were investigated using multilevel (hierarchical) modelling. Results: 1,030 patients were randomised to doctor-mask wearing consultations (n = 514) and non mask wearing consultations (n = 516). A significant and negative effect was found in the patients’ perception of the doctors’ empathy (CARE score reduction �0.98, p-value = 0.04). In the more established doctor-patient relationship, the effect of doctors’ mask wearing was more pronounced (CARE score reduction �5.67, p-value = 0.03). Conclusion: This study demonstrates that when doctors wearing a facemask during consultations, this has a significant negative impact on the patient’s perceived empathy and diminish the positive effects of relational continuity. Consideration should be taken in planning appropriate use of facemasks in infectious disease policy for primary care and other healthcare professionals at a national, local or practice level.

Views and experiences of nurse practitioners and medical practitioners with collaborative practice in primary health care - an integrative review.

Abstract: This integrative review synthesises research studies that have investigated the perceptions of nurse practitioners and medical practitioners working in primary health care. The aggregation of evidence on barriers and facilitators to working collaboratively and experiences about the processes of collaboration is of value to understand success factors and factors that impede collaborative working relationships. An integrative review, which used systematic review processes, was undertaken to summarise qualitative and quantitative studies published between 1990 and 2012. Databases searched were the Cochrane Library, the Joanna Briggs Institute Library, PubMed, Medline, CINAHL, Informit and ProQuest. Studies that met the inclusion criteria were assessed for quality. Study findings were extracted relating to a) barriers and facilitators to collaborative working and b) views and experiences about the process of collaboration. The findings were narratively synthesised, supported by tabulation. 27 studies conducted in seven different countries met the inclusion criteria. Content analysis identified a number of barriers and facilitators of collaboration between nurse practitioners and medical practitioners. By means of data comparison five themes were developed in relation to perceptions and understanding of collaboration. Nurse practitioners and medical practitioners have differing views on the essentials of collaboration and on supervision and autonomous nurse practitioner practice. Medical practitioners who have a working experience with NPs express more positive attitudes towards collaboration. Both professional groups report concerns and negative experiences with collaborative practice but also value certain advantages of collaboration. The review shows that working in collaboration is a slow progression. Exposure to working together helps to overcome professional hurdles, dispel concerns and provide clarity around roles and the meaning of collaboration of NPs and MPs. Guidelines on liability and better funding strategies are necessary to facilitate collaborative practice whether barriers lie in individual behaviours or in broader policies.

Comorbidity in patients with chronic obstructive pulmonary disease in family practice: a cross sectional study.

Abstract: Chronic obstructive pulmonary disease (COPD) is frequent and often coexists with other diseases. The aim of this study was to quantify the prevalence of COPD and related chronic comorbidity among patients aged over 40 years visiting family practices in an area of Madrid. An observational, descriptive, cross-sectional study was conducted in a health area of the Madrid Autonomous Region (Comunidad Autonoma de Madrid). The practice population totalled 198,670 persons attended by 129 Family Physicians (FPs), and the study population was made up of persons over the age of 40 years drawn from this practice population. Patients were deemed to have COPD if this diagnosis appeared on their clinical histories. Prevalence of COPD; prevalence of a further 25 chronic diseases in patients with COPD; and standardised prevalence ratios, were calculated. Prevalence of COPD in family medicine was 3.2% (95% CI 3.0–3.3) overall, 5.3% among men and 1.4% among women; 90% of patients presented with comorbidity, with a mean of 4 ± 2.04 chronic diseases per patient, with the most prevalent related diseases being arterial hypertension (52%), disorders of lipid metabolism (34%), obesity (25%), diabetes (20%) and arrhythmia (15%). After controlling for age and sex, the observed prevalence of the following ten chronic diseases was higher than expected: heart failure; chronic liver disease; asthma; generalised artherosclerosis; osteoporosis; ischaemic heart disease; thyroid disease; anxiety/depression; arrhythmia; and obesity. Patients with COPD, who are frequent in family practice, have a complex profile and pose a clinical and organisational challenge to FPs.

Barriers, facilitators and attitudes influencing health promotion activities in general practice: an explorative pilot study

Abstract: Background: The number of chronically ill patients increases every year. This is partly due to an unhealthy lifestyle. However, the frequency and quality of (evidence-based) health promotion activities conducted by Dutch general practitioners (GPs) and practice nurses (PNs) are limited. The aim of this pilot study was to explore which lifestyle interventions Dutch GPs and PNs carry out in primary care, which barriers and facilitators can be identified and what main topics are with respect to attitudes towards health promoting activities. These topic areas will be identified for a future, larger scale study. Method: This qualitative study consisted of 25 semi-structured interviews with sixteen GPs and nine PNs. ATLAS.ti was used to analyse the transcripts of the interviews. Results: All GPs and PNs said they discuss lifestyle with their patients. Next to this, GPs and PNs counsel patients, and/or refer them to other disciplines. Only few said they refer patients to specific lifestyle programs or interventions in their own practice or in the neighbourhood. Several barriers and facilitators were identified. The main topics as barriers are: a lack of patients’ motivation to make lifestyle changes, insufficient reimbursement, a lack of proven effectiveness of interventions and a lack of overview of health promoting programs in their neighbourhood. The most cited facilitators are availability of a PN, collaboration with other disciplines and availability of interventions in their own practice. With respect to attitudes, six different types of GPs were identified reflecting the main topics that relate to attitudes, varying from ‘ignorer’ to ‘nurturer’. The topics relating to PNs attitudes towards health promotion activities, were almost unanimously positive.

General practitioners’ experiences and perceptions of benzodiazepine prescribing: systematic review and meta-synthesis

Abstract: Benzodiazepines are often prescribed long-term inappropriately. We aimed to systematically review and meta-synthesise qualitative studies exploring clinicians’ experiences and perceptions of benzodiazepine prescribing to build an explanatory model of processes underlying current prescribing practices. We searched seven electronic databases for qualitative studies in Western primary care settings published in a European language between January 1990 and August 2011 analysing GP or practice nurse experiences of benzodiazepine prescribing. We assessed study quality using the Critical Appraisal Skills Programme Checklist. We analysed findings using thematic synthesis. We included eight studies from seven countries published between 1993 and 2010. Benzodiazepine prescribing decisions are complex, uncomfortable, and demanding, taken within the constraints of daily general practice. Different GPs varied in the extent to which they were willing to prescribe benzodiazepines, and individual GPs’ approaches also varied. GPs were ambivalent in their attitude towards prescribing benzodiazepines and inconsistently applied management strategies for their use. This was due to the changing context of prescribing, differing perceptions of the role and responsibility of the GP, variation in GPs’ attitudes to benzodiazepines, perceived lack of alternative treatment options, GPs’ perception of patient expectations and the doctor-patient relationship. GPs faced different challenges in managing initiation, continuation and withdrawal of benzodiazepines. We have developed a model which could be used to inform future interventions to improve adherence to benzodiazepine prescribing guidance and improve prescribing through education and training of professionals on benzodiazepine use and withdrawal, greater provision of alternatives to drugs, reflective practice, and better communication with patients.

How QOF is shaping primary care review consultations: a longitudinal qualitative study.

Abstract: Long-term conditions (LTCs) are increasingly important determinants of quality of life and healthcare costs in populations worldwide. The Chronic Care Model and the NHS and Social Care Long Term Conditions Model highlight the use of consultations where patients are invited to attend a consultation with a primary care clinician (practice nurse or GP) to complete a review of the management of the LTC. We report a qualitative study in which we focus on the ways in which QOF (Quality and Outcomes Framework) shapes routine review consultations, and highlight the tensions exposed between patient-centred consulting and QOF-informed LTC management.

Impact of communicative and critical health literacy on understanding of diabetes care and self-efficacy in diabetes management: a cross-sectional study of primary care in Japan

Abstract: Background: The role of a patient’s functional health literacy (HL) has received much attention in the context of diabetes education, but researchers have not fully investigated the roles of communicative and critical HL, especially in primary care. Communicative HL is the skill to extract health information and derive meaning from different forms of communication, and to apply this information to changing circumstances. Critical HL allows the patient to critically analyze information and to use this information to achieve greater control over life events and situations. We examined how HL, particularly communicative and critical HL, is related to the patient’s understanding of diabetes care and self-efficacy for diabetes management in primary care settings. We also examined the impact of patient–physician communication factors on these outcomes, taking HL into account. Methods: We conducted a cross-sectional observational study of 326 patients with type 2 diabetes who were seen at 17 primary care clinics in Japan. The patients completed a self-administered questionnaire that assessed their HL (functional, communicative, and critical), understanding of diabetes care, and self-efficacy for diabetes management. We also examined the perceived clarity of the physician’s explanation to assess patient–physician communication. Multivariate regression analyses were performed to determine whether HL and patient–physician communication were associated with understanding of diabetes care and self-efficacy. Results: A total of 269 questionnaires were analyzed. Communicative and critical HL were positively associated with understanding of diabetes care (β = 0.558, 0.451, p < 0.001) and self-efficacy (β = 0.365, 0.369, p < 0.001), respectively. The clarity of physician’s explanation was associated with understanding of diabetes care (β = 0.272, p < 0.001) and self-efficacy (β = 0.255, p < 0.001). In multivariate regression models, HL and perceived clarity of the physician’s explanation were independently associated with understanding of diabetes care and self-efficacy. Conclusions: Communicative and critical HL and clear patient–physician communication were independently associated with the patient’s understanding of diabetes care and self-efficacy. The potential impact of communicative and critical HL should be considered in communications with, and the education of, patients with diabetes in primary care settings.

Factors influencing insulin acceptance among type 2 diabetes mellitus patients in a primary care clinic: a qualitative exploration.

Abstract: Background Many Type 2 Diabetes Mellitus (T2DM) patients refuse insulin therapy even when they require this modality of treatment. However, some eventually accept insulin. This study aimed to explore the T2DM patients’ reasons for accepting insulin therapy and their initial barriers to use insulin.

A qualitative descriptive study on the alignment of care goals between older persons with multi-morbidities, their family physicians and informal caregivers.

Abstract: Goal setting is a recommended approach in clinical care that can help individuals with multi-morbidities and their caregivers manage chronic conditions. In this paper, the types of goals that were important for older persons with multi-morbidities were explored from the perspectives of patients, their caregivers and physicians. Comparisons of goals were made across each patient, caregiver and physician triad to determine alignment. The study was a qualitative descriptive study facilitated through semi-structured one-on-one interviews. The study took place between May and October 2012 at a Family Health Team located in Ontario, Canada. The sample included 28 family medicine patients, their informal caregivers and family physicians. Socio-demographic data were analyzed via descriptive statistics in SPSS Version 17. Open ended questions pertaining to patient goals of care were analyzed thematically using NVivo9. Themes were derived on patient care goals for each of the participant groups (patients, caregivers and family physicians). Following this, alignment of goals across each of the triads was examined. Goal alignment was defined as concurrence on at least one goal by all three parties in a particular triad (i.e., patient, caregiver and family physician). Just over half of the patients were male (56%); they had an average age of 82.3 years and 4.61 health conditions. Most of the caregivers were female (82%); and 61% were a spouse of the care recipient. At the aggregate level, common goals expressed among patients, caregivers and family physicians were the maintenance of functional independence of patients and the management of their symptoms or functional challenges. Despite these common goals at the aggregate level, little alignment of goals was found when looking across patient-caregiver and physician triads. Lack of alignment tended to occur when patients had unstable or declining functional or cognitive health; when safety threats were noted; and when enhanced care services were required. The data suggest that goal divergence tends to occur when patients are less medically stable. While goal divergence may be expected due to the different roles and responsibilities of each of the players involved, these perspectives should be illuminated when building care plans. Further research is required to observe the extent to which goal setting occurs in family practice as well as how it can be embedded as a standard of practice.

Parents’ information needs, self-efficacy and influences on consulting for childhood respiratory tract infections: a qualitative study

Abstract: Background Acute respiratory tract infection (RTI) is the most common reason why parents consult primary care in the UK. Little is known about parents’ perceptions of what may help them to make an appropriate decision to consult when their child is ill and how to improve self-care. Using qualitative methods, this study aimed to explore parents’ views on support and information needs prior to consulting when children have RTIs with cough, and identify the triggers and barriers to consulting primary care.

Primary care clinicians' attitudes towards point-of-care blood testing: a systematic review of qualitative studies.

Abstract: Background Point-of-care blood tests are becoming increasingly available and could replace current venipuncture and laboratory testing for many commonly used tests. However, at present very few have been implemented in most primary care settings. Understanding the attitudes of primary care clinicians towards these tests may help to identify the barriers and facilitators to their wider adoption. We aimed to systematically review qualitative studies of primary care clinicians’ attitudes to point-of-care blood tests.

Physical activity on prescription (PAP) from the general practitioner's perspective - a qualitative study

Abstract: Physical activity on prescription (PAP) is a successful intervention for increasing physical activity among patients with a sedentary lifestyle. The method seems to be sparsely used by general practitioners (GPs) and there is limited information about GPs’ attitudes to counselling using PAP as a tool. The aim of the study was to explore and understand the meaning of prescribing physical activity from the general practitioner’s perspective. Three focus group interviews were conducted with a purposive sample of 15 Swedish GPs in the south of Sweden. Participants were invited to talk about their experience of using PAP. The interviews were transcribed verbatim, analysed using qualitative content analysis. The analysis resulted in four categories: The tradition makes it hard to change attitude, Shared responsibility is necessary, PAP has low status and is regarded with distrust and Lack of procedures and clear guidelines. Traditionally GPs talk with patients about the importance of an increased level of physical activity but they do not prescribe physical activity as a treatment. Physician’s education focuses on the use of pharmaceuticals. The responsibility for patients’ physical activity level is shared with other health professionals, the patient and society. The GPs express reservations about prescribing physical activity. A heavy workload is a source of frustration. PAP is regarded with distrust and considered to be a task of less value and status. Using a prescription to emphasize an increased level is considered to be redundant and the GPs think it should be administered by someone else in the health care system. Scepticism about the result of the method was also expressed. There is uncertainty about using PAP as a treatment since physicians lack education in non-pharmaceutical methods. The GPs do not regard the written referral as a prioritized task and rather refer to other professionals in the health care system to prescribe PAP. GPs pointed out a need to create routines and arrangements for the method to gain credibility and become everyday practice among GPs.

Women with symptoms of uncomplicated urinary tract infection are often willing to delay antibiotic treatment: a prospective cohort study

Abstract: Women presenting with symptoms of acute uncomplicated urinary tract infection (UTI) are often prescribed antibiotics. However, in 25 to 50% of symptomatic women not taking antibiotics, symptoms recover spontaneously within one week. It is not known how many women are prepared to delay antibiotic treatment. We investigated how many women presenting with UTI symptoms were willing to delay antibiotic treatment when asked by their general practitioner (GP). From 18 April 2006 until 8 October 2008, in a prospective cohort study, patients were recruited in 20 GP practices in and around Amsterdam, the Netherlands. Healthy, non-pregnant women who contacted their GP with painful and/or frequent micturition for no longer than seven days registered their symptoms and collected urine for urinalysis and culture. GPs were requested to ask all patients if they were willing to delay antibiotic treatment, without knowing the result of the culture at that moment. After seven days, patients reported whether their symptoms had improved and whether they had used any antibiotics. Of 176 women, 137 were asked by their GP to delay antibiotic treatment, of whom 37% (51/137) were willing to delay. After one week, 55% (28/51) of delaying women had not used antibiotics, of whom 71% (20/28) reported clinical improvement or cure. None of the participating women developed pyelonephritis. More than a third of women with UTI symptoms are willing to delay antibiotic treatment when asked by their GP. The majority of delaying women report spontaneous symptom improvement after one week.

Patient and physician related factors of adherence to evidence based guidelines in diabetes mellitus type 2, cardiovascular disease and prevention: a cross sectional study.

Abstract: Background: Patients do not always receive guideline-adherent therapy, yet little is known about the underlying causes on the patients’ side. We quantified non-guideline-adherent treatment of chronic diseases (diabetes mellitus, hypertension, cardiovascular disease, heart failure, atrial fibrillation) in primary care and analysed the causes from the physician’s as well as the patient’s view. Methods: With the intention to analyze the frequency and causes of non-guideline-adherent treatment of patients with chronic diseases, we drew a random sample of 124 general practitioners (GP) in Salzburg, Austria, of which 58 (46.8%) participated. In the participating GP surgeries, we consecutively recruited 501 patients with at least one of the target-diseases and checked the guideline conformity of treatment using 9 quality indicators. We then interviewed the patients as well as the general practitioners regarding factors affecting deviation from guideline recommendations. Results: Of the 501 patients, a total of 1224 quality indicators could be analysed. Non-adherence to guideline recommendations were present in 16.8% (n = 205, 95% CI 14.7 to 18.8%) of all quality indicators. In 61.5% of these cases (n = 126, 95% CI 53.0 to 70.0%) the treatment was wrongly judged as not recommended by the physicians. In 10.2% (n = 21, 95% CI 0 to 23.2%) physicians attributed non-adherence to patient’s non-compliance, and in 10.7% (n = 22, 95% CI 0 to 23.7%) to an adverse drug event, whereas only 5.4% (n = 11, 95% CI 0 to 18.7%) of nonadherence was related to an adverse drug event reported by the patients. Patients were unaware regarding the reason for non-adherent therapy in 64.4% (n = 132, 95% CI 56.2 to 72.6%) of the quality indicators. In 20.0% (n = 41, 95% CI 7.8 to 32.2%) patients regarded a drug as not needed. Conclusions: Guideline adherence in chronic care was relatively good in our study sample, but still leaving room for improvement. Physicians’ lack of knowledge and patients’ lack of awareness account for about 70% of non-adherence, indicating the necessity to improve physician education, and patient involvement. In about 30% of the quality indicators not fulfilled, non-adherence is due to other reasons like adverse drug events or patients not willing to take a recommended drug.

Improvement in the management of gout is vital and overdue: an audit from a UK primary care medical practice

Abstract: Gout is estimated to affect 1.4% of adults in the UK. Appropriate and timely management is essential to reduce the risk of further flares, complications, and to reduce cardiovascular disease risk. The British Society for Rheumatology and British Health Professionals in Rheumatology (BSR/BHPR) and the European League Against Rheumatism (EULAR) have published guidance regarding the management of gout, thereby providing standards against which performance can be measured. This audit was designed to assess the extent to which patients diagnosed with gout in one primary care medical practice in North Staffordshire, UK, are managed in accordance with current best practice guidelines, and to identify strategies for improvement where appropriate. Audit criteria were derived from the EULAR and BSR/BHPR guidelines; standards were set arbitrarily, but with consideration of patient comorbidity and other factors which may influence concordance. An electronic search of the practice records was performed to identify adults with a diagnosis of gout. Medical record review with a descriptive analysis was undertaken to assess the extent to which medical management adhered to the predefined standards. Of the total ≥18 year-old practice population (n = 8686), 305 (3%) patient records included a diagnosis of gout. Of these, 74% (n = 226) had an electronic record of serum uric acid (SUA), and 11% (n = 34) and 53% (n = 162) a measure of estimated glomerular filtration rate (eGFR) ever and serum glucose since diagnosis respectively. 34% (n = 105) of patients had ever taken urate-lowering therapy with 25% (n = 77) currently prescribed this at the time of data extraction. Dose adjustment and monitoring of treatment according to SUA was found to be inadequate. Provision of lifestyle advice and consideration of comorbidities was also lacking. The primary care management of gout in this practice was not concordant with national and international guidance, a finding consistent with previous studies. This demonstrates that the provision of guidelines alone is not sufficient to improve the quality of gout management and we identify possible strategies to increase guideline adherence.

How do general practitioners experience providing care to refugees with mental health problems? A qualitative study from Denmark

Abstract: Refugees are a particularly vulnerable group in relation to the development of mental illness and many may have been subjected to torture or other traumatic experiences. General practitioners are gatekeepers for access to several parts of the psychiatric system and knowledge of their patients’ refugee background is crucial to secure adequate care. The aim of this study is to investigate how general practitioners experience providing care to refugees with mental health problems. The study was conducted as part of an EU project on European Best Practices in Access, Quality and Appropriateness of Health Services for Immigrants in Europe (EUGATE). Semi-structured interviews were carried out with nine general practitioners in the vicinity of Copenhagen purposively selected from areas with a high proportion of immigrants. The analysis of the interviews is inspired by qualitative content analysis. One of the main themes identified in the analysis is communication. This includes the use of professional interpreters and that communication entails more than sharing a common language. Quality of care is another theme that emerges and includes awareness of possible trauma history, limited possibilities for refugees to participate in certain treatments due to language barriers and feelings of hopelessness in the general practitioners. The general practitioners may also choose different referral pathways for refugees and they report that their patients lack understanding regarding the differences between psychological problems and physical symptoms. General practitioners experience that providing care to refugees differs from providing care for patients from the majority population. The different strategies employed by the general practitioners in the health care treatment of refugees may be the result of the great diversity in the organisation of general practice in Denmark and the lack of a national strategy in the health care management of refugees. The findings from this study suggest that the development of conversational models for general practitioners including points to be aware of in the treatment of refugee patients may serve as a support in the management of refugee patients in primary care.

The integration of occupational therapy into primary care: a multiple case study design

Abstract: For over two decades occupational therapists have been encouraged to enhance their roles within primary care and focus on health promotion and prevention activities. While there is a clear fit between occupational therapy and primary care, there have been few practice examples, despite a growing body of evidence to support the role. In 2010, the province of Ontario, Canada provided funding to include occupational therapists as members of Family Health Teams, an interprofessional model of primary care. The integration of occupational therapists into this model of primary care is one of the first large scale initiatives of its kind in North America. The objective of the study was to examine how occupational therapy services are being integrated into primary care teams and understand the structures supporting the integration. A multiple case study design was used to provide an in-depth description of the integration of occupational therapy. Four Family Health Teams with occupational therapists as part of the team were identified. Data collection included in-depth interviews, document analyses, and questionnaires. Each Family Health Team had a unique organizational structure that contributed to the integration of occupational therapy. Communication, trust and understanding of occupational therapy were key elements in the integration of occupational therapy into Family Health Teams, and were supported by a number of strategies including co-location, electronic medical records and team meetings. An understanding of occupational therapy was critical for integration into the team and physicians were less likely to understand the occupational therapy role than other health providers. With an increased emphasis on interprofessional primary care, new professions will be integrated into primary healthcare teams. The study found that explicit strategies and structures are required to facilitate the integration of a new professional group. An understanding of professional roles, trust and communication are foundations for interprofessional collaborative practice.

Perceived facilitators and barriers in diabetes care: a qualitative study among health care professionals in the Netherlands.

Abstract: The need to understand barriers to the implementation of health care innovations in daily practice has been widely documented, but perceived facilitators and barriers in diabetes care by Dutch health care professionals remain unknown. The aim of this study was to investigate these factors among health care professionals (HCPs) using a qualitative research design. Data were collected from 18 semi-structured interviews with HCPs from all professions relevant to diabetes care. The interviews were recorded and transcribed verbatim and the data were analyzed using NVivo 8.0. Major facilitators were the more prominent role of the practice nurses and diabetes nurses in diabetes care, benchmarking, the Care Standard (CS) of the Netherlands Diabetes federation and multidisciplinary collaboration, although collaboration with certain professional groups (i.e. dieticians, physical therapists and pharmacists), as well as the collaboration between primary and secondary care, could still be improved. The bundled payment system for the funding of diabetes care and the role of the health insurers were perceived as major barriers within the health care system. Other important barriers were reported to be the lack of motivation among patients and the lack of awareness of lifestyle programs and prevention initiatives for diabetes patients among professionals. Organizational changes in diabetes care, as a result of the increased attention given to management continuity of care, have led to an increased need for multidisciplinary collaboration within and between health care sectors (e.g. public health, primary care and secondary care). To date, daily routines for shared care are still sub-optimal and improvements in facilities, such as registration systems, should be implemented to further optimize communication and exchange of information.

Improving chronic disease prevention and screening in primary care: results of the BETTER pragmatic cluster randomized controlled trial

Abstract: Background Primary care provides most of the evidence-based chronic disease prevention and screening services offered by the healthcare system. However, there remains a gap between recommended preventive services and actual practice. This trial (the BETTER Trial) aimed to improve preventive care of heart disease, diabetes, colorectal, breast and cervical cancers, and relevant lifestyle factors through a practice facilitation intervention set in primary care.

An observational descriptive study of the epidemiology and treatment of neuropathic pain in a UK general population

Abstract: Background: This study updated our knowledge of UK primary care neuropathic pain incidence rates and prescribing practices. Methods: Patients with a first diagnosis of post-herpetic neuralgia (PHN), painful diabetic neuropathy (PDN) or phantom limb pain (PLP) were identified from the General Practice Research Database (2006 – 2010) and incidence rates were calculated. Prescription records were searched for pain treatments from diagnosis of these conditions and the duration and daily dose estimated for first-line and subsequent treatment regimens. Recording of neuropathic back and post-operative pain was investigated. Results: The study included 5,920 patients with PHN, 5,340 with PDN, and 185 with PLP. The incidence per 10,000 person-years was 3.4 (95% CI 3.4, 3.5) for PHN; and 0.11 (95% CI 0.09, 0.12) for PLP. Validation of the PDN case definition suggested that was not sensitive. Incident PHN increased over the study period. The most common first-line treatments were amitriptyline or gabapentin in the PDN and PLP cohorts, and amitriptyline or co-codamol (codeine-paracetamol) in PHN. Paracetamol, co-dydramol (paracetamol-dihydrocodeine) and capsaicin were also often prescribed in one or more condition. Most first-line treatments comprised only one therapeutic class. Use of antiepileptics licensed for neuropathic pain treatment had increased since 2002–2005. Amitriptyline was the only antidepressant prescribed commonly as a first-line treatment. Conclusion: The UK incidence of diagnosed PHN has increased with the incidence of back-pain and post-operative pain unclear. While use of licenced antiepileptics increased, prescribing of therapy with little evidence of efficacy in neuropathic pain is still common and consequently treatment was often not in-line with current guidance.

Accessibility to primary health care in Belgium: an evaluation of policies awarding financial assistance in shortage areas

Abstract: Background In many countries, financial assistance is awarded to physicians who settle in an area that is designated as a shortage area to prevent unequal accessibility to primary health care. Today, however, policy makers use fairly simple methods to define health care accessibility, with physician-to-population ratios (PPRs) within predefined administrative boundaries being overwhelmingly favoured. Our purpose is to verify whether these simple methods are accurate enough for adequately designating medical shortage areas and explore how these perform relative to more advanced GIS-based methods.

Barriers and facilitating factors for disease self-management: a qualitative analysis of perceptions of patients receiving care for type 2 diabetes and/or hypertension in San José, Costa Rica and Tuxtla Gutiérrez, Mexico

Abstract: The burden of cardiovascular disease is growing in the Mesoamerican region. Patients’ disease self-management is an important contributor to control of cardiovascular disease. Few studies have explored factors that facilitate and inhibit disease self-management in patients with type 2 diabetes and hypertension in urban settings in the region. This article presents patients’ perceptions of barriers and facilitating factors to disease self-management, and offers considerations for health care professionals in how to support them. In 2011, 12 focus groups were conducted with a total of 70 adults with type 2 diabetes and/or hypertension who attended urban public health centers in San Jose, Costa Rica and Tuxtla Gutierrez, Chiapas, Mexico. Focus group discussions were transcribed and coded using a content analysis approach to identify themes. Themes were organized using the trans-theoretical model, and other themes that transcend the individual level were also considered. Patients were at different stages in their readiness-to-change, and barriers and facilitating factors are presented for each stage. Barriers to disease self-management included: not accepting the disease, lack of information about symptoms, vertical communication between providers and patients, difficulty negotiating work and health care commitments, perception of healthy food as expensive or not filling, difficulty adhering to treatment and weight loss plans, additional health complications, and health care becoming monotonous. Factors facilitating disease self-management included: a family member’s positive experience, sense of urgency, accessible health care services and guidance from providers, inclusive communication, and family and community support. Financial difficulty, gender roles, differences by disease type, faith, and implications for families and their support were identified as cross-cutting themes that may add an additional layer of complexity to disease management at any stage. These factors also relate to the broader family and societal context in which patients live. People living with type 2 diabetes and hypertension present different barriers and facilitating factors for disease self-management, in part based on their readiness-to-change and also due to the broader context in which they live. Primary care providers can work with individuals to support self-management taking into consideration these different factors and the unique situation of each patient.

Identifying frailty: do the Frailty Index and Groningen Frailty Indicator cover different clinical perspectives? a cross-sectional study

Abstract: Early identification of frailty is important for proactive primary care. Currently, however, there is no consensus on which measure to use. Therefore, we examined whether a Frailty Index (FI), based on ICPC-coded primary care data, and the Groningen Frailty Indicator (GFI) questionnaire identify the same older people as frail. We conducted a cross-sectional, observational study of 1,580 patients aged ≥ 60 years in a Dutch primary care center. Patients received a GFI questionnaire and were surveyed on their baseline characteristics. Frailty-screening software calculated their FI score. The GFI and FI scores were compared as continuous and dichotomised measures. FI data were available for 1549 patients (98%). 663 patients (42%) returned their GFI questionnaire. Complete GFI and FI scores were available for 638 patients (40.4%), mean age 73.4 years, 52.8% female. There was a positive correlation between the GFI and the FI (Pearson’s correlation coefficient 0.544). Using dichotomised scores, 84.3% of patients with a low FI score also had a low GFI score. In patients with a high FI score, 55.1% also had a high GFI score. A continuous FI score accurately predicted a dichotomised GFI score (AUC 0.78, 95% CI 0.74 to 0.82). Being widowed or divorced was an independent predictor of both a high GFI score in patients with a low FI score, and a high FI score in patients with a low GFI score. The FI and the GFI moderately overlap in identifying frailty in community-dwelling older patients. To provide optimal proactive primary care, we suggest an initial FI screening in routine healthcare data, followed by a GFI questionnaire for patients with a high FI score or otherwise at high risk as the preferred two-step frailty screening process in primary care.

Generalist solutions to complex problems: generating practice-based evidence - the example of managing multi-morbidity

Abstract: Background: A growing proportion of people are living with long term conditions. The majority have more than one. Dealing with multi-morbidity is a complex problem for health systems: for those designing and implementing healthcare as well as for those providing the evidence informing practice. Yet the concept of multi-morbidity (the presence of >2 diseases) is a product of the design of health care systems which define health care need on the basis of disease status. So does the solution lie in an alternative model of healthcare? Discussion: Strengthening generalist practice has been proposed as part of the solution to tackling multi-morbidity. Generalism is a professional philosophy of practice, deeply known to many practitioners, and described as expertise in whole person medicine. But generalism lacks the evidence base needed by policy makers and planners to support service redesign. The challenge is to fill this practice-research gap in order to critically explore if and when generalist care offers a robust alternative to management of this complex problem. We need practice-based evidence to fill this gap. By recognising generalist practice as a ‘complex intervention’ (intervening in a complex system), we outline an approach to evaluate impact using action-research principles. We highlight the implications for those who both commission and undertake research in order to tackle this problem. Summary: Answers to the complex problem of multi-morbidity won’t come from doing more of the same. We need to change systems of care, and so the systems for generating evidence to support that care. This paper contributes to that work through outlining a process for generating practice-based evidence of generalist solutions to the complex problem of person-centred care for people with multi-morbidity.

The “Health Coaching” programme: a new patient-centred and visually supported approach for health behaviour change in primary care

Abstract: Health related behaviour is an important determinant of chronic disease, with a high impact on public health. Motivating and assisting people to change their unfavourable health behaviour is thus a major challenge for health professionals. The objective of the study was to develop a structured programme of counselling in primary care practice, and to test its feasibility and acceptance among general practitioners (GPs) and their patients. Our new concept integrates change of roles, shared responsibility, patient-centredness, and modern communication techniques—such as motivational interviewing. A new colour-coded visual communication tool is used for the purpose of leading through the 4-step counselling process. As doctors’ communication skills are crucial, communication training is a mandatory part of the programme. We tested the feasibility and acceptance of the “Health Coaching” programme with 20 GPs and 1045 patients, using questionnaires and semistructured interviewing techniques. The main outcomes were participation rates; the duration of counselling; patients’ self-rated behavioural change in their areas of choice; and ratings of motivational, conceptual, acceptance, and feasibility issues. In total, 37% (n=350) of the patients enrolled in step 1 completed the entire 4-Step counselling process, with each step taking 8–22 minutes. 50% of ratings (n=303) improved by one or two categories in the three-colour circle, and the proportion of favourable health behaviour ratings increased from 9% to 39%. The ratings for motivation, concept, acceptance, and feasibility of the “Health Coaching” programme were consistently high. Our innovative, patient-centred counselling programme for health behaviour change was well accepted and feasible among patients and physicians in a primary care setting. Randomised controlled studies will have to establish cost-effectiveness and promote dissemination.

Predictors of relational continuity in primary care: patient, provider and practice factors

Abstract: Continuity is a fundamental tenet of primary care, and highly valued by patients; it may also improve patient outcomes and lower cost of health care. It is thus important to investigate factors that predict higher continuity. However, to date, little is known about the factors that contribute to continuity. The purpose of this study was to analyse practice, provider and patient predictors of continuity of care in a large sample of primary care practices in Ontario, Canada. Another goal was to assess whether there was a difference in the continuity of care provided by different models of primary care. This study is part of the larger a cross-sectional study of 137 primary care practices, their providers and patients. Several performance measures were evaluated; this paper focuses on relational continuity. Four items from the Primary Care Assessment Tool were used to assess relational continuity from the patient’s perspective. Multilevel modeling revealed several patient factors that predicted continuity. Older patients and those with chronic disease reported higher continuity, while those who lived in rural areas, had higher education, poorer mental health status, no regular provider, and who were employed reported lower continuity. Providers with more years since graduation had higher patient-reported continuity. Several practice factors predicted lower continuity: number of MDs, nurses, opening on weekends, and having 24 hours a week or less on-call. Analyses that compared continuity across models showed that, in general, Health Service Organizations had better continuity than other models, even when adjusting for patient demographics. Some patients with greater health needs experience greater continuity of care. However, the lower continuity reported by those with mental health issues and those who live in rural areas is concerning. Furthermore, our finding that smaller practices have higher continuity suggests that physicians and policy makers need to consider the fact that ‘bigger is not always necessarily better’.